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Improving Health and Health Care
in Greater Cincinnati through
Data Transparency
Dr. Richard Shonk, Chief Medical Officer
Greater Cincinnati Health Council
The Health Collaborative
HealthBridge
Who We Are
Neutral forum for all stakeholders
Those providing
health care
Those receiving
health care
Those paying
health care
Unique Collaboration
Health
Systems
Health
Plans
Employers
7,500 CONNECTED PHYSICIANS
Cooperation
Health systems, health plans and
employers have a 21 year history of
cooperation.
Quality
Currently leading successful QI
initiatives in physician offices and in
the hospital setting.
Infrastructure
Capacity to securely collect and
manage health data files. Soon be
receiving Medicare Data
Greater Cincinnati is one of the nation’s most connected health care communities
with 7,500 connected physicians and a high adoption of electronic medical
records. We are ahead of most other US cities in this regard.
Vision
To inspire breakthroughs
in transforming health
and health care
Greater Cincinnati: Leading with
National Distinction
The only community in America with this unique array
of improvement programs and infrastructure.
Quality
Improvement
Payment
Realignment
Data Collection
& Public
Reporting
ONC Beacon
Community
CMS
Comprehensive
Primary Care
Initiative
RWJF
Aligning Forces
for Quality
Health IT &
Exchange
Services
Population
Health &
Consumer
Engagement
Collective Impact
ONC Regional
on Health;
Extension Center
YourHealthMatters
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Leveraging the Investment
Goal: Better Health, Better Care, Lower Cost
What is needed?
• Transformation expertise
• Coordination of resources
• Multi-stakeholder relationships
• IT connectivity and data exchange
• Tracking quality, cost, satisfaction, utilization
• Public reporting of results
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Vision vs. Reality
Fee for Service
Pay for Value
- BARRIER -
Payers Lack
Clinical Quality Data
Providers Lack
Cost Data
Patients Lack
Both
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How do we address the
challenges?
We are working across the region on common issues
Shared Community Agenda
Payment Realignment
Greater Cincinnati
1 of only 7
75 practices and
261 providers
Multi- payer:
9 health plans +
Medicare
300,000 estimated
commercial,
Medicaid and
Medicare enrollees
chosen sites nationally
65 miles
from
Williamstown, KY to Piqua, OH
Cincinnati/Dayton/Northern Kentucky
CPC Market
75 Practices:
• ~2/3 System affiliated
• ~1/3 Independent
Quality & Data Transparency:
•71% Public Reporting Initiative
•49% NCQA PCMH recognition
•25% 2008 standards
•24% 2011 standards
•90% attested for MU Stage 1
EHRs:
•Epic-59%
•AllScripts-23%
•Athena-13%
•McKesson-3%
•NextGen-1%
•Amazing Charts-1%
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Cincinnati/Dayton/Northern Kentucky
CPC Market
• 11 Payers
• Amerigroup (Ohio only)
• CareSource (Ohio only)
• Centene Corporation (Ohio only)
• Ohio Medicaid within the Ohio Department of Job and Family
Services
• CMS - Medicare “fee for service”
• Aetna
• Anthem Blue Cross Blue Shield of Ohio
• Humana
• HealthSpan
• Medical Mutual
• UnitedHealthcare
• Estimated 44,500 Medicare beneficiaries
• Estimated 250,000 Commercial, Medicaid, and Medicare
Advantage
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Cincinnati/Dayton/Northern Kentucky
CPC – Quality Measures
Quality Metrics:
• 21 NQF endorsed measures
• 2 patient experience (CG-CAHPS)
• 3 care utilization (Claims)
• 6 preventive health/ screenings (EHR)
• 10 chronic disease/ at-risk population (EHR)
( 2 metrics are deferred until 2015)
• Meeting Targets (TBD) required to be eligible for
shared savings and continued participation
• Begin tracking one utilization and one quality metric
in 2013
• Begin reporting all 19 measures to CMS in 2014 (CY
2013 as baseline)
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CPC Payment Model
Care
management
pmpm; “fee for
service”
Medicare and
Ohio Medicaid
beneficiaries
Shared
Savings
(2014-2016)
Care management
PMPM; private
health plans for
commercial, MA,
Medicaid lines of
business
YourHealthMatters.org
Data Collection & Public Reporting
Primary Care
Providers Diabetes
•
Cardiovascular Health
•
Colon Cancer
Screening Rates
•
Patient Experience
Hospital
•
•
•
Effectiveness
Patient Experience
Emergency Department
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YHM Diabetes Quality Info
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Greater
Cincinnati has
118 PatientCentered
Medical Homes
– one of the
highest rates in
the nation
Consumers can
search for the
nearest PCMH
Providers’ Early Experiences with Quality Reporting
using Clinical Data
Providers all thought they scored higher
Sure there was a problem with the report
Review of data against chart (EHR or paper) – can’t argue with your own
data (at least not as much)
Wanted to score better next year
Beneficial for staff members to review the data before
submission
Especially true when one staff member assigned to provider
Blanks make a great visual
Awareness of data needed for quality reporting
Realized they played a role in quality improvement
All providers saw that an EHR is good but not enough.
wanted a better way to track their patients with chronic conditions
wanted tools for more frequent reporting and data for improvement
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State Innovation Model
Payers and Providers
Recognize the Need
for Better Data
Physician Practice = New Focus of
Performance Measurement
Necessary for Accountable Care
Data Infrastructure for Medical Home
Expansion & Episode of Care Payments
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Regional Data Aggregation
Our New Challenge
Need for a neutral, trusted, local source of
truth - no one payor or provider has the whole
picture
Payment is proceeding toward “payment for
value” away from “fee for service” - need a
community-wide view of cost and utilization for
decision support and benchmarking
Consistent and continuous method to monitor
progress year over year
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Cost Transparency Trends &
Impact on Greater Cincinnati
What Health Care Providers Need to Know
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Cost & Quality Variability
Research is conclusive: There is tremendous
inexplicable quality, cost and price variability in
the US health care system.
The Dartmouth Atlas team has documented substantial
and persistent regional variation that cannot be explained
by differences in Medicare beneficiaries’ demographic
characteristics, health status nor by the quality of the
health care they receive.
A report by Castlight Health from June 2014 found
tremendous variation in cost for common tests and
imaging – even in the same city tests and imaging can
differ 4-23 times in cost.
Why is this such a big issue?
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Ohio Price List Comparison:
Which one would you choose if you were paying the bill?
Comparison of Selected Ohio Hospital List Prices
for Labor & Deliver Services
Hospital/ Health System
[1]
Vaginal Delivery
Cesarean Section Delivery
TriHealth
$5,532.00
$7,905.00
The Christ Hospital
$6,450.00
$8,502.00
OhioHealth
$4,251.00
$4,339.00
Mercy Health
$4,780.50
$6,718.50
TriHealth hospital list prices available at http://www.trihealth.com/discover-trihealth/about-us/pricing/Good-Samaritan-and-Bethesda-North-Prices-EffectiveJuly-1-2014.aspx
[2] The Christ Hospital list prices available at
http://www.thechristhospital.com/upload/docs/Patient%20Services/BillingAndInsurance/Copy%20of%20tch%20price%20disclosure%20for%20intranet050113OP
.pdf
[3] OhioHealth hospital list prices are available at
https://www.ohiohealth.com/uploadedfiles/ohio_health_site/tools_and_resources/patient_and_visitor_guides/ohiohealth_price_information_list.pdf
[4] Mercy Health Hospital list prices available at http://www.e-mercy.com/billing-and-insurance.aspx
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New Trends in Transparency
Cost and Quality Transparency is a key feature of
value-based purchasing.
Better information = better decisions
A number of new payer initiatives and programs are
accelerating move to value-based purchasing:
Reference Pricing
Narrow Networks
Lower out of pocket costs for patients that choose high
value providers
More cost and quality information available publicly
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CMS Transparency Efforts
Hospital Compare website now routinely provides on information on
average hospital-specific charges per patient and average Medicare
payments for the most common diagnosis-related groups (DRGs);
Similar price transparency is expected for the Physician Compare
website.
The Physician Feedback/Value-Based Payment Modifier Program
begins in January 2015 and expands over two years to cover all
physicians in the US receiving payments from CMS.
Under the program, CMS will increase or decrease Medicare
physician payments using a value-based payment modifier.
The 2016 modifier is calculated from physician performance data
from two years prior in 2014. (e.g., PQRS and cost data)
Qualified Entity Certification Program – Push Medicare claims
data out to trusted sources for performance improvement analysis
CMS’s value-based payments, cost transparency and
open data efforts will continue to grow steadily in the
coming years.
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Health Benefits & Enrollment Trends
Employees with high deductible benefit plans grew from 10 percent
in 2006 to 38 percent overall in 2013, with the rate among small
employers reaching 58 percent.
Enrollment in the Federal Health Insurance Marketplace as of
February 1, 2014 showed that 62 percent of enrollees had selected
silver plans, 19 percent selected bronze plans, and 1 percent
selected catastrophic coverage.
More than 80 percent of new marketplace enrollees will face
higher cost-sharing requirements, including significant
deductibles.
Half of exchange products feature narrow networks.
More cost sharing = comparison shopping for
lower cost, higher quality services.
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Employer & Plan Trends
CalPERS Reference Pricing Initiative
In 2011, CalPERS implemented reference pricing for hip and knee
replacements.
CalPERS collected data and frequently updated a list of providers who
met or beat its reference price.
Steered members to higher value providers through intensive
communication about provider price differences – little pushback from
members – wanted to receive the information
Result: saved an estimated $2.8 million for plan and an additional
$300,000 for its members; CalPERS paid 30 percent less per surgery
on average in 2011 compared to 2010.
Caused tremendous change in market share and increase in hospital
competition on price
Source: J Robinson and T Brown, “Increases In Consumer Cost Sharing Redirect Patient
Volumes And Reduce Hospital Prices For Orthopedic Surgery,” Health Affairs, August 2013,
Vol. 32, No. 8, 1392-1397.
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Employer & Plan Trends
MRI Price Transparency Initiative
•
Company comparison study of MRIs in 2010 and 2012.
•
Looked at two subgroups based on whether their commercial insurer
was participating in the MRI price transparency program.
•
The intervention group was informed about pricing at different facilities
and given the option of selecting different providers.
•
Members contacted shifted from more expensive hospital-based
facilities to free-standing facilities which reduced costs by $220 or by
nearly 19 percent per test.
•
The program had the added benefit for insurers in that it sparked
competition among facilities, resulting in a further 30 percent reduction
in differences between hospital and non-hospital based facilities for
the intervention group.
Source: S Wu, G Sylwestrzak, C Shah and A DeVries, “Price Transparency For MRIs
Increased Use Of Less Costly Providers And Triggered Provider Competition,” Health
Affairs, August 2014 Vol. 33 No. 8 1391-1398.
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Other Transparency Efforts
The Health Care Cost Institute (HCCI)
a non-partisan, non-profit organization launched in September 2011
supported by Aetna, Humana, Kaiser Permanente, and United Healthcare
Aim: Create the first complete, comprehensive national claims
database with information on health care utilization and costs;
Analyze and report regularly to the public on national, regional, and state
trends in health care spending and utilization;
Promote the efforts of states to improve the functioning of their health care
systems by supporting innovative activities such as all-payer claims
databases and transparency initiatives; and
Castlight Health
founded in 2008 by Todd Park, Bryan Roberts and Giovanni Colella.
Castlight’s technology enables employers to empower employees with the
information
Set of applications enables employers to deliver cost-effective
benefits,provide medical professionals and health plans a merit-based
market to showcase their services, and empower employees to make
informed healthcare choices with a clear understanding of costs and likely
outcomes.
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Cost Measurement
Critical challenge for providers: how to define and
measure cost:
Various cost methodologies are used to reward or
penalize providers, define in and out of network
providers and measure value.
Challenges: patient attribution, calculation of cost,
risk adjustment and the appropriateness of care.
Some payer algorithms simply assign to a single
provider all spending for a group of patients in a
given time period.
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Cost Measurement
Problems can occur when cost calculations do not account for
the following:
Patients don’t see their care provider in the given time
frame, thereby leaving out healthy, no cost patients from
cost calculations,
Care occurs in settings the provider has no control over,
Cost categories are excluded from calculations (e.g.,
payer cost calculations sometimes exclude prescription
drugs),
Risk adjustment models only include historic information
and do not take into consideration newly diagnosed
health care conditions, and
There is no distinction between the appropriateness or
inappropriateness of services provided.
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Cost Measurement
National Quality Forum has endorsed the
HealthPartners Total Cost of Care (TCOC) and
Resource Use measure –
TCOC includes two parts:
the cost of care provided to a patient (or “Total Cost
Index”)
measurement of resources used in providing that
care (or “Total Resource Use Index”)
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Cost Measurement
NRHI Healthcare Regional Cost Measurement and
Transparency Pilot - five regional collaboratives
developing standard means to measure and publicly
report on total cost of care and resource use
Greater Cincinnati Health Collaborative working on:
Aggregating claims data from multiple payers
Investigating adding cost measurement into
available data sets
Wedding claims and clinical data electronically for
more robust understanding of cost and quality
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What to Expect
Health care providers need to plan now for a marketplace
where cost and price information will be freely available to
consumers, their employers and the media.
Plans will increasingly use reference pricing, narrow
networks in provider contract negotiations.
As more information becomes available, expect:
Increased market share volatility as patients are incentivized to
visit higher quality, lower cost providers
Tough contract negotiations with plans
increased media scrutiny
uncomfortable questions from policy makers (Medicaid,
Medicare, state legislature, etc.)
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Recommendations
Be proactive: conduct further analysis of cost measurement and
transparency and develop action strategy.
Collaborate to Develop Expertise: Work with us to develop
regional expertise (leveraging national relationships/experts) on
Cost Transparency and Total Cost of Care Measurement.
Partner on the Collection and Analysis of Cost Data: support
development of a regional database with total cost measure
analysis.
Prioritize the development of a regional training strategy: help
providers to understand and act upon cost and utilization metrics.
Support public reporting of cost/value measures alongside quality
information on www.YourHealthMatters.org.